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Recovery of microorganisms from the pelvic cavity after intracervical or intrauterine artificial insemination
Vol. 46, No. I, July 1986 Printed in U.8A.
FERTILITY AND STERILITY Copyright e 1986 The American Fertility Society
Recovery of microorganisms from the pelvic cavity after intracervical or intrauterine artificial insemination
Sergio C. Stone, M.D. * Luis M. de la Maza, M.D., Ph.D.t Ellena M. Peterson, Ph.D.t:j: University of California Irvine Medical Center, Orange, California
To assess the risk of introducing microorganisms into the peritoneal cavity during intracervical or intrauterine insemination, we cultured the cervix and semen from 19 couples before insemination and the peritoneal fluid from the female partner after insemination. The peritoneal cultures taken before hydrotubation grew organisms in one of ten intracervical inseminations and five of the nine intrauterine inseminations (P < 0.05). In four of the five positive peritoneal cultures from the intrauterine group, the organism was also cultured from the semen specimen obtained before insemination and not from the cervical sample. Therefore, intrauterine insemination appears to increase the risk of introducing microorganisms into the upper genital tract and the peritoneal cavity. The clinical significance of this finding remains to be established. Fertil Steril46:61, 1986
It has been shown previously that semen used for artifical insemination (AI) may be contaminated with a variety of microorganisms, some of them potential pathogens. I, 2 Nevertheless, AI programs have reported a very low incidence of symptomatic pelvic infections. 3 An increasing number of centers are presently using intrauterine AI. This procedure bypasses the cervical mucus, which is generally considered a barrier for ascending infections. 4 - 7 In the present study, patients were inseminated by the cervical or the intrauterine method, and after insemination, the patients were examined for the presence of micro-
Received December 10, 1985; revised and accepted March 13, 1986. *Department of Obstetrics and Gynecology. tDepartment of Pathology. :j:Reprint requests: Ellena M. Peterson, Ph.D., Department of Pathology, University of California, Irvine, Orange, California 92668. Vol. 46, No.1, July 1986
organisms in the peritoneal cavity for determination of whether the intrauterine technique predisposes women to a higher risk of pelvic inflammatory disease. MATERIALS AND METHODS
From a patient population with unexplained infertility, we selected 19 couples undergoing a diagnostic laparoscopy with a sperm recovery test. s The mean patient age was 31.3 years, with a range between 28 and 39 years. Thirteen patients were nulligravidas, and the 6 patients with secondary infertility had previously a total of nine pregnancies, with three normal term deliveries. The group of 19 couples was homogeneous in that a complete infertility evaluation was negative. A laparoscopy was considered as the next diagnostic step. Cultures were taken from the cervical mucus and the husband's semen before insemination. Stone et a1. Microorganisms in pelvic cavity after AI
61
Semen samples were collected by masturbation! ejaculation into a sterile glass container. For the insemination, the ovulatory day of the cycle was determined by ultrasound. When a follicle measuring at least 18 mm in diameter was observed, an intramuscular injection of 5000 IU of human chorionic gonadotropin (hCG) was given. Twentyfour hours later, ten patients received an intracervical insemination, and nine underwent intrauterine insemination. Because all couples had been given diagnoses of unexplained infertility and were considered identical, they were randomly assigned one of the two types of insemination. In the intracervical group, 2 ml of semen was deposited in the cervical canal, and a plastic tampon was used to keep it in place. The intrauterine inseminations were done after the semen was centrifuged, washed, and resuspended in Ham's F-I0 solution. The insemination was done with a total of 0.2 ml. All husbands had numerous previous semen analyses, and all were considered within normal limits for fertility. During the laparoscopy, done 2 to 4 hours later, the peritoneal fluid in the cul-de-sac was aspirated. A second sample was obtained after hydrotubation with sterile s;::tline with the use of a small cervical cone manipulator, 37 mm long. Both samples were cultured and observed microscopically for the presence of sperm immediately after collection and later in the laboratory, after centrifugation, resuspension, and staining. 8 The results were analyzed with the use of Fisher's exact test. All samples obtained for cultures were processed within 3 hours of collection by the following procedures. ROUTINE AEROBIC AND ANAEROBIC CULTURES
Aliquots of cervical mucus, semen, and peritoneal fluid, before and after hydrotubation, were plated onto 5% sheep blood, MacConkey, chocolate, and modified Thayer-Martin agars. These plates were incubated at 35°C in 5% CO 2 up to 72 hours. Media used for recovery of anaerobes included Brucella and lincomycin-kanamycinvancomycin agars as well as chopped meat glucose broth. Anaerobic media was incubated (35°C) in a Gas-Pak jar (BBL, Cockeysville, MD) for up to 5 days. Anaerobes were speciated in all peritoneal cultures and only in cervical and semen cultures when an anaerobe was cultured from the peritoneal fluid. 62
Stone et al. Microorganisms in pelvic cavity after AI
CHLAMYDIA
Aliquots of all specimens were suspended in Eagle's minimal essential medium (MEM), and this was used to inoculate a monolayer of McCoy cells that were grown on glass coverslips in I-dram glass vials. Cultures were then processed as previously described. 9 MYCOPLASMA
Aliquots of all specimens were suspended in MEM, and this was used to inoculate the following: glucose agar, A7 agar, urea and arginine broth. The A7 medium was incubated under anaerobic conditions, the glucose agar in 5% CO 2 , and the broths in air. All substrates were examined each day and held at 35°C for 7 days. VIRUSES
Upon suspension in Eagle's MEM, all samples were inoculated into three tubes each of cynomolgus monkey kidney, MRC-5, and Hep-2 cell lines. Cell cultures were held for 14 days and examined each day for cytopathic effect. MICRO IMMUNOFLUORESCENCE
Microimmunofluorescence with the use of Chlamydia trachomatis antigens was performed according to the procedure described by Wang and Grayston. lO
RESULTS An aliquot of the semen used for insemination was cultured for microorganisms from all but four donors. All semen specimens contained from two to seven types of microorganisms. These organisms were mainly Staphylococcus epidermidis, viridans streptococci, and gram-negative rods, which are considered skin or mucosa contaminants. In addition, one semen sample contained Ureaplasma urealyticum and Mycoplasm spp., and another grew Gardnerella vaginalis, all of which have been implicated in sexually transmitted diseases. These organisms are not usually considered normal skin flora and possibly represent urethral contamination of the semen. The cervical mucus was cultured from all patients; and all, with the exception of one with no growth, grew normal vaginal/cervical flora. In addition, U. urealyticum was isolated from three Fertility and Sterility
Table 1. Results of Peritoneal Cultures Hydrotubation Type of insemination
No. of patients
Sperm recovered, no. of patients
Positive n (%)
n (%)
n (%)
n (%)
10 9
3 3
1 (10) 5 (55.6)
9 (90) 4 (44.4)
3 (30) 6 (66.7)
7 (70) 3 (33.3)
Intracervical Intrauterine
patients and G. vaginalis from one female patient. After insemination, organisms were recovered from the peritoneal cavity before hydrotubation in five out of the nine patients who received an intrauterine insemination and from only one in the intracervical insemination group (Table 1). This difference was statistically significant (P = 0.0495). With the exception of one, in all patients where the prehydrotubation peritoneal culture was positive, the organism(s) was present in the semen and not the cervix, a finding that suggests that the contamination was related to the donor semen (Table 2). Organisms recovered in the prehydrotubation samples could be considered skin contaminants possibly introduced into the semen sample during collection. The one exception was a G. vaginalis isolate, which is considered by some to be a sexually transmitted organism. Cultures of the posthydrotubation samples were positive in three of the ten patients in the intracervical group and in six of the nine patients from the intrauterine group. In the intracervical group, there were a total of five organisms recov-
Before
After Negative
Positive
Negative
ered in the three culture-positive patients, and all but one of the organisms was also cultured from the cervix. In contrast, of the seven isolates from the intrauterine group, one was recovered only from the cervix, one from both the cervix and semen, and five from the semen only. G. vaginal is was recovered in posthydrotubation cultures from one patient in each of both groups. The same organism was recovered only from the cervix of the patient in the intracervical group and from the donor semen only in the intrauterine group. Although U. urealyticum was recovered from 4 patients in the study (3 from the cervix, 1 from semen), none was recovered from the peritoneal cultures. Similarly, all viral and Chlamydia cultures were negative. Microimmunofluorescent titers to C. trachomatis were positive (titer, > 32) in 5 of the 13 (38%) females tested. Sperm were recovered from the peritoneal cavity before hydrotubation in 30% (3 of 10) of patients in the intracervical group and in 33% (3 of 9) of those in the intrauterine group (Table 1). There was no correlation between sperm recovery and positive peritoneal cultures. In two patients
Table 2. Organisms Isolated from Peritoneal Cultures Procedure
Patient no.
Intracervical
4 5 13
Intrauterine
1 2 10 16 17 18
Organism Diphtheroid Staphylococcus epidermidis Peptococcus asaccharolyticus Gardnerella vaginalis Bacteroides asaccharolyticus Gaffkya anaerobia Streptococcus MG-intermedius Staphylococcus epidermidis Staphylococcus epidermidis Propionibacterium acnes Streptococcus faecalis Gardnerella vaginalis Pseudomonas sp. Propionibacterium acnes
Cervix"
Semen"
+ +
+ + +
+ + + + +
+
+ + + + + +
Peritoneal cavity (hydrotubation) Before After
+
+ + + + +
+ + + + + + + + + + + +
aAll cervical and semen cultures from the patients listed grew multiple organisms. A minus (-) means the particular organism referred to was not among those recovered from that site.
Vol. 46, No. I, July 1986
Stone et aI. Microorganisms in pelvic cavity after AI
63
in the intracervical and one in the intrauterine group with positive sperm recovery tests, corresponding peritoneal cultures were negative. DISCUSSION
Our results indicate that intrauterine AI, in comparison with intracervical AI, increases the risk of introducing microorganisms into the peritoneal cavity of the patient. The organisms that appear to be preferentially transferred are those present in the semen used for AI. It is well known that normal cervical mucus l l ,12 and semen 1,2 may contain a large variety of contaminant microorganisms. It is accepted that the cervical mucus and the cervical canal act as a physiologic barrier that keeps most of these organisms from ascending to the upper female genital tract, so that only occasionally a clinical infection develOpS.4-7 This mechanism may explain.the low reported incidence of overt infections after intracervical Als or normal intercourse. 3 On the other hand, it has been demonstrated in vitro that microorganisms can be carried by sperm through a cervical mucus column, though microorganisms alone do not appear to ascend. 13 Passive transfer of nonmotile inorganic material from the lower to the upper genital canals can occur, which indicates that sperm may not be the only mechanism for the transport of microorganisms to the uterus, tubes, or peritoneal cavity.14 Likewise, in this report, in only approximately half of the patients with positive prehydrotubation peritoneal cultures could sperm be recovered. Therefore, sperm cannot be the only explanation for the transport of microorganisms into the peritoneum. There is a potential for infection in any AI, and this potential may be increased with the use of an intrauterine insemination technique that deposits sperm and microorganisms directly in the uterine cavity, bypassing the cervical mucus barrier. The cervical mucus does function as a barrier, allowing a preferential transport of sperm and decreasing the passage of microorganisms to the peritoneum. 4-7 We have shown that microorganisms can be isolated from 56% of patients who undergo intrauterine AI, as compared with only 10% in cases of intracervical AI. This difference is highly significant. Therefore, the presence of microorganisms in the peritoneal fluid before hydrotubation suggests that intrauterine AI increases the risk of transferring microorganisms to the upper genital tract .. As expected, there is an 64
Stone et al. Microorganisms in pelvic cavity after AI
increase in the number of positive peritoneal fluid cultures after hydrotubation that is probably related to the manipulation during the procedure with possible forceful transfer of microorganisms. The intrauterine technique may also have a higher potential for the development of clinical or subclinical infections than that recognized and reported for intracervical Als. We have no clear explanation for the absence of symptoms in our patients in whom we recovered microorganisms from the peritoneum. Whether subclinical infection actually develops and leads to mild tubal inflammation and local mucosal damage is only speculative at this time. It is also possible that the number of contaminating organisms is small and/or that the host defense mechanisms have the capacity to dispose of this type of contamination effectively. We can conclude (1) that after AI, microorganisms can be recovered from the peritoneal cavity, (2) that intrauterine AI significantly increases the risk of transferring microorganisms to the peritoneal cavity, as compared with the intracervical technique,and (3) that, although no symptoms developed in our patients, infection may be a potential serious complication.
REFERENCES 1. Garcia A, Sierra MF, Friberg J: Survival of bacteria after
2.
3. 4.
5.
6. 7.
8.
9.
freezing of human semen in liquid nitrogen. Fertil Steril 35:549, 1981 Leiva JL, Peterson EM, Wetkowski ME, de la Maza LM, Stone S: Microorganisms in semen used for artificial insemination. Obstet Gynecol 65:669, 1985 Stone SC: Complications and pitfalls of artificial insemination. Clin Obstet Gynecol 23:667, 1980 Vaerman JP, Ferin J: Local immunological response in the vagina, cervix, and endometrium. In Immunological Approaches to Fertility Control, Edited by E Diczfalusy. Copenhagen, Bogtrykkeriet Forum, 1974, p 281 Rebello R, GreenFHY: A study of the secretory immune system of the female genital tract. Br J Obstet Gynaecol 82:812, 1975 Zuckerman H, Kahana A, Carmel S: Antibacterial activity of human cervical mucus. Gynecol Invest 6:265, 1975 Elstein M: Cervical mucus: its physiological role and clinical significance. In Advances in Experimental Medicine and Biology, Vo1144, Edited by EN Chandler, JB Elder, M Elstein. New York, Plenum Press, 1982, p 301 Stone SC: Peritoneal recovery of sperm in patients with infertility associated with inadequate cervical mucus. Fertil Steril 40:802, 1983 Aarnaes SL, Peterson EM, de la Maza LM: The effect of media and temperature on the storage of Chlamydia trachomatis. J Clin Path 81:237, 1984
Fertility and Sterility
10. Wang SOP, Grayston JT: Micro.immunofluorescence serology of Chlamydia trachomatis. In Medical Virology III, Edited by LM de la'Maza, EM Peterson. New York, Elsevier Science Publishing, 1984, p 87 11. Corbishly CM: Microbial flora ofthe vagina and cervix. J Clin Pathol 30:745, 1977
Vol. 46, No.1, July 1986
12. Ohm MH, Galask RP: 'Bacterial flora of the cervix from 100 prehysterectomy patients. Am J Obstet Gynecol 122:683, 1975 13. Toth A, O'Leary WM, Ledger W: Evidence of microbial transfer by spermatozoa. Obstet Gynecol 59:566, 1982 14. Stone SC, McCalley M, Braunstein P, Egbert R: Radionuclide evaluation of tubal function. Fertil Steril43:757, 1985
Stone et aI. Microorganisms in pelvic cavity after AI
65
FERTILITY AND STERILITY Copyright e 1986 The American Fertility Society
Recovery of microorganisms from the pelvic cavity after intracervical or intrauterine artificial insemination
Sergio C. Stone, M.D. * Luis M. de la Maza, M.D., Ph.D.t Ellena M. Peterson, Ph.D.t:j: University of California Irvine Medical Center, Orange, California
To assess the risk of introducing microorganisms into the peritoneal cavity during intracervical or intrauterine insemination, we cultured the cervix and semen from 19 couples before insemination and the peritoneal fluid from the female partner after insemination. The peritoneal cultures taken before hydrotubation grew organisms in one of ten intracervical inseminations and five of the nine intrauterine inseminations (P < 0.05). In four of the five positive peritoneal cultures from the intrauterine group, the organism was also cultured from the semen specimen obtained before insemination and not from the cervical sample. Therefore, intrauterine insemination appears to increase the risk of introducing microorganisms into the upper genital tract and the peritoneal cavity. The clinical significance of this finding remains to be established. Fertil Steril46:61, 1986
It has been shown previously that semen used for artifical insemination (AI) may be contaminated with a variety of microorganisms, some of them potential pathogens. I, 2 Nevertheless, AI programs have reported a very low incidence of symptomatic pelvic infections. 3 An increasing number of centers are presently using intrauterine AI. This procedure bypasses the cervical mucus, which is generally considered a barrier for ascending infections. 4 - 7 In the present study, patients were inseminated by the cervical or the intrauterine method, and after insemination, the patients were examined for the presence of micro-
Received December 10, 1985; revised and accepted March 13, 1986. *Department of Obstetrics and Gynecology. tDepartment of Pathology. :j:Reprint requests: Ellena M. Peterson, Ph.D., Department of Pathology, University of California, Irvine, Orange, California 92668. Vol. 46, No.1, July 1986
organisms in the peritoneal cavity for determination of whether the intrauterine technique predisposes women to a higher risk of pelvic inflammatory disease. MATERIALS AND METHODS
From a patient population with unexplained infertility, we selected 19 couples undergoing a diagnostic laparoscopy with a sperm recovery test. s The mean patient age was 31.3 years, with a range between 28 and 39 years. Thirteen patients were nulligravidas, and the 6 patients with secondary infertility had previously a total of nine pregnancies, with three normal term deliveries. The group of 19 couples was homogeneous in that a complete infertility evaluation was negative. A laparoscopy was considered as the next diagnostic step. Cultures were taken from the cervical mucus and the husband's semen before insemination. Stone et a1. Microorganisms in pelvic cavity after AI
61
Semen samples were collected by masturbation! ejaculation into a sterile glass container. For the insemination, the ovulatory day of the cycle was determined by ultrasound. When a follicle measuring at least 18 mm in diameter was observed, an intramuscular injection of 5000 IU of human chorionic gonadotropin (hCG) was given. Twentyfour hours later, ten patients received an intracervical insemination, and nine underwent intrauterine insemination. Because all couples had been given diagnoses of unexplained infertility and were considered identical, they were randomly assigned one of the two types of insemination. In the intracervical group, 2 ml of semen was deposited in the cervical canal, and a plastic tampon was used to keep it in place. The intrauterine inseminations were done after the semen was centrifuged, washed, and resuspended in Ham's F-I0 solution. The insemination was done with a total of 0.2 ml. All husbands had numerous previous semen analyses, and all were considered within normal limits for fertility. During the laparoscopy, done 2 to 4 hours later, the peritoneal fluid in the cul-de-sac was aspirated. A second sample was obtained after hydrotubation with sterile s;::tline with the use of a small cervical cone manipulator, 37 mm long. Both samples were cultured and observed microscopically for the presence of sperm immediately after collection and later in the laboratory, after centrifugation, resuspension, and staining. 8 The results were analyzed with the use of Fisher's exact test. All samples obtained for cultures were processed within 3 hours of collection by the following procedures. ROUTINE AEROBIC AND ANAEROBIC CULTURES
Aliquots of cervical mucus, semen, and peritoneal fluid, before and after hydrotubation, were plated onto 5% sheep blood, MacConkey, chocolate, and modified Thayer-Martin agars. These plates were incubated at 35°C in 5% CO 2 up to 72 hours. Media used for recovery of anaerobes included Brucella and lincomycin-kanamycinvancomycin agars as well as chopped meat glucose broth. Anaerobic media was incubated (35°C) in a Gas-Pak jar (BBL, Cockeysville, MD) for up to 5 days. Anaerobes were speciated in all peritoneal cultures and only in cervical and semen cultures when an anaerobe was cultured from the peritoneal fluid. 62
Stone et al. Microorganisms in pelvic cavity after AI
CHLAMYDIA
Aliquots of all specimens were suspended in Eagle's minimal essential medium (MEM), and this was used to inoculate a monolayer of McCoy cells that were grown on glass coverslips in I-dram glass vials. Cultures were then processed as previously described. 9 MYCOPLASMA
Aliquots of all specimens were suspended in MEM, and this was used to inoculate the following: glucose agar, A7 agar, urea and arginine broth. The A7 medium was incubated under anaerobic conditions, the glucose agar in 5% CO 2 , and the broths in air. All substrates were examined each day and held at 35°C for 7 days. VIRUSES
Upon suspension in Eagle's MEM, all samples were inoculated into three tubes each of cynomolgus monkey kidney, MRC-5, and Hep-2 cell lines. Cell cultures were held for 14 days and examined each day for cytopathic effect. MICRO IMMUNOFLUORESCENCE
Microimmunofluorescence with the use of Chlamydia trachomatis antigens was performed according to the procedure described by Wang and Grayston. lO
RESULTS An aliquot of the semen used for insemination was cultured for microorganisms from all but four donors. All semen specimens contained from two to seven types of microorganisms. These organisms were mainly Staphylococcus epidermidis, viridans streptococci, and gram-negative rods, which are considered skin or mucosa contaminants. In addition, one semen sample contained Ureaplasma urealyticum and Mycoplasm spp., and another grew Gardnerella vaginalis, all of which have been implicated in sexually transmitted diseases. These organisms are not usually considered normal skin flora and possibly represent urethral contamination of the semen. The cervical mucus was cultured from all patients; and all, with the exception of one with no growth, grew normal vaginal/cervical flora. In addition, U. urealyticum was isolated from three Fertility and Sterility
Table 1. Results of Peritoneal Cultures Hydrotubation Type of insemination
No. of patients
Sperm recovered, no. of patients
Positive n (%)
n (%)
n (%)
n (%)
10 9
3 3
1 (10) 5 (55.6)
9 (90) 4 (44.4)
3 (30) 6 (66.7)
7 (70) 3 (33.3)
Intracervical Intrauterine
patients and G. vaginalis from one female patient. After insemination, organisms were recovered from the peritoneal cavity before hydrotubation in five out of the nine patients who received an intrauterine insemination and from only one in the intracervical insemination group (Table 1). This difference was statistically significant (P = 0.0495). With the exception of one, in all patients where the prehydrotubation peritoneal culture was positive, the organism(s) was present in the semen and not the cervix, a finding that suggests that the contamination was related to the donor semen (Table 2). Organisms recovered in the prehydrotubation samples could be considered skin contaminants possibly introduced into the semen sample during collection. The one exception was a G. vaginalis isolate, which is considered by some to be a sexually transmitted organism. Cultures of the posthydrotubation samples were positive in three of the ten patients in the intracervical group and in six of the nine patients from the intrauterine group. In the intracervical group, there were a total of five organisms recov-
Before
After Negative
Positive
Negative
ered in the three culture-positive patients, and all but one of the organisms was also cultured from the cervix. In contrast, of the seven isolates from the intrauterine group, one was recovered only from the cervix, one from both the cervix and semen, and five from the semen only. G. vaginal is was recovered in posthydrotubation cultures from one patient in each of both groups. The same organism was recovered only from the cervix of the patient in the intracervical group and from the donor semen only in the intrauterine group. Although U. urealyticum was recovered from 4 patients in the study (3 from the cervix, 1 from semen), none was recovered from the peritoneal cultures. Similarly, all viral and Chlamydia cultures were negative. Microimmunofluorescent titers to C. trachomatis were positive (titer, > 32) in 5 of the 13 (38%) females tested. Sperm were recovered from the peritoneal cavity before hydrotubation in 30% (3 of 10) of patients in the intracervical group and in 33% (3 of 9) of those in the intrauterine group (Table 1). There was no correlation between sperm recovery and positive peritoneal cultures. In two patients
Table 2. Organisms Isolated from Peritoneal Cultures Procedure
Patient no.
Intracervical
4 5 13
Intrauterine
1 2 10 16 17 18
Organism Diphtheroid Staphylococcus epidermidis Peptococcus asaccharolyticus Gardnerella vaginalis Bacteroides asaccharolyticus Gaffkya anaerobia Streptococcus MG-intermedius Staphylococcus epidermidis Staphylococcus epidermidis Propionibacterium acnes Streptococcus faecalis Gardnerella vaginalis Pseudomonas sp. Propionibacterium acnes
Cervix"
Semen"
+ +
+ + +
+ + + + +
+
+ + + + + +
Peritoneal cavity (hydrotubation) Before After
+
+ + + + +
+ + + + + + + + + + + +
aAll cervical and semen cultures from the patients listed grew multiple organisms. A minus (-) means the particular organism referred to was not among those recovered from that site.
Vol. 46, No. I, July 1986
Stone et aI. Microorganisms in pelvic cavity after AI
63
in the intracervical and one in the intrauterine group with positive sperm recovery tests, corresponding peritoneal cultures were negative. DISCUSSION
Our results indicate that intrauterine AI, in comparison with intracervical AI, increases the risk of introducing microorganisms into the peritoneal cavity of the patient. The organisms that appear to be preferentially transferred are those present in the semen used for AI. It is well known that normal cervical mucus l l ,12 and semen 1,2 may contain a large variety of contaminant microorganisms. It is accepted that the cervical mucus and the cervical canal act as a physiologic barrier that keeps most of these organisms from ascending to the upper female genital tract, so that only occasionally a clinical infection develOpS.4-7 This mechanism may explain.the low reported incidence of overt infections after intracervical Als or normal intercourse. 3 On the other hand, it has been demonstrated in vitro that microorganisms can be carried by sperm through a cervical mucus column, though microorganisms alone do not appear to ascend. 13 Passive transfer of nonmotile inorganic material from the lower to the upper genital canals can occur, which indicates that sperm may not be the only mechanism for the transport of microorganisms to the uterus, tubes, or peritoneal cavity.14 Likewise, in this report, in only approximately half of the patients with positive prehydrotubation peritoneal cultures could sperm be recovered. Therefore, sperm cannot be the only explanation for the transport of microorganisms into the peritoneum. There is a potential for infection in any AI, and this potential may be increased with the use of an intrauterine insemination technique that deposits sperm and microorganisms directly in the uterine cavity, bypassing the cervical mucus barrier. The cervical mucus does function as a barrier, allowing a preferential transport of sperm and decreasing the passage of microorganisms to the peritoneum. 4-7 We have shown that microorganisms can be isolated from 56% of patients who undergo intrauterine AI, as compared with only 10% in cases of intracervical AI. This difference is highly significant. Therefore, the presence of microorganisms in the peritoneal fluid before hydrotubation suggests that intrauterine AI increases the risk of transferring microorganisms to the upper genital tract .. As expected, there is an 64
Stone et al. Microorganisms in pelvic cavity after AI
increase in the number of positive peritoneal fluid cultures after hydrotubation that is probably related to the manipulation during the procedure with possible forceful transfer of microorganisms. The intrauterine technique may also have a higher potential for the development of clinical or subclinical infections than that recognized and reported for intracervical Als. We have no clear explanation for the absence of symptoms in our patients in whom we recovered microorganisms from the peritoneum. Whether subclinical infection actually develops and leads to mild tubal inflammation and local mucosal damage is only speculative at this time. It is also possible that the number of contaminating organisms is small and/or that the host defense mechanisms have the capacity to dispose of this type of contamination effectively. We can conclude (1) that after AI, microorganisms can be recovered from the peritoneal cavity, (2) that intrauterine AI significantly increases the risk of transferring microorganisms to the peritoneal cavity, as compared with the intracervical technique,and (3) that, although no symptoms developed in our patients, infection may be a potential serious complication.
REFERENCES 1. Garcia A, Sierra MF, Friberg J: Survival of bacteria after
2.
3. 4.
5.
6. 7.
8.
9.
freezing of human semen in liquid nitrogen. Fertil Steril 35:549, 1981 Leiva JL, Peterson EM, Wetkowski ME, de la Maza LM, Stone S: Microorganisms in semen used for artificial insemination. Obstet Gynecol 65:669, 1985 Stone SC: Complications and pitfalls of artificial insemination. Clin Obstet Gynecol 23:667, 1980 Vaerman JP, Ferin J: Local immunological response in the vagina, cervix, and endometrium. In Immunological Approaches to Fertility Control, Edited by E Diczfalusy. Copenhagen, Bogtrykkeriet Forum, 1974, p 281 Rebello R, GreenFHY: A study of the secretory immune system of the female genital tract. Br J Obstet Gynaecol 82:812, 1975 Zuckerman H, Kahana A, Carmel S: Antibacterial activity of human cervical mucus. Gynecol Invest 6:265, 1975 Elstein M: Cervical mucus: its physiological role and clinical significance. In Advances in Experimental Medicine and Biology, Vo1144, Edited by EN Chandler, JB Elder, M Elstein. New York, Plenum Press, 1982, p 301 Stone SC: Peritoneal recovery of sperm in patients with infertility associated with inadequate cervical mucus. Fertil Steril 40:802, 1983 Aarnaes SL, Peterson EM, de la Maza LM: The effect of media and temperature on the storage of Chlamydia trachomatis. J Clin Path 81:237, 1984
Fertility and Sterility
10. Wang SOP, Grayston JT: Micro.immunofluorescence serology of Chlamydia trachomatis. In Medical Virology III, Edited by LM de la'Maza, EM Peterson. New York, Elsevier Science Publishing, 1984, p 87 11. Corbishly CM: Microbial flora ofthe vagina and cervix. J Clin Pathol 30:745, 1977
Vol. 46, No.1, July 1986
12. Ohm MH, Galask RP: 'Bacterial flora of the cervix from 100 prehysterectomy patients. Am J Obstet Gynecol 122:683, 1975 13. Toth A, O'Leary WM, Ledger W: Evidence of microbial transfer by spermatozoa. Obstet Gynecol 59:566, 1982 14. Stone SC, McCalley M, Braunstein P, Egbert R: Radionuclide evaluation of tubal function. Fertil Steril43:757, 1985
Stone et aI. Microorganisms in pelvic cavity after AI
65